Female Genital Mutilation: A Global Health Perspective

Imagine a procedure in which a child is cut in a highly personal area in a highly painful manner, with no say in the matter whatsoever. Associated with this procedure are complications ranging from infection and bleeding all the way to death. From many perspectives, this procedure is a violation of the child’s basic human rights. However, this procedure is condoned in and is part of the accepted cultural practices in 30 countries in Africa, the Middle East and Asia1. Known as female genital mutilation (FGM), it has been performed for millennia and is one of myriad examples of gender inequality issues plaguing global health today.

What is FGM?

A road sign near Kapchorwa, Uganda as part of a campaign against female genital mutilation. Source: Amnon Shavit, via Wikimedia Commons.

FGM, formerly referred to as female circumcision, involves the removal of all or part of the female genitalia and is typically carried out on girls before the onset of puberty. The World Health Organization (WHO) classifies FGM procedures into four categories based on the extent of mutilation: Type 1, clitoridectomy, involves total or partial removal of the clitoris; Type 2, excision, involves total or partial removal of the clitoris and labia; Type 3, infibulation, involves narrowing of the vaginal opening by creating a covering seal using existing tissue; and Type 4, which includes all other non-medicinal procedures harmful to the female genitalia.

The WHO reports that “FGM has no health benefits, and it harms girls and women in many ways.”1 Harms associated with FGM, most frequent and severe in Type 3 FGM, can be both immediate and long-term. Immediate complications include pain, infection, bleeding and sepsis, all of which can be fatal in severe cases. Long-term complications include difficulty in childbirth, anemia, incontinence, sexual dysfunction and increased risk for contraction of HIV/AIDS or other sexually transmitted infections.2 A 2006 WHO study published in the journal The Lancet examined birth outcomes in women who underwent FGM and showed that women with Type 3 FGM were 70% more likely than women who had not undergone FGM to suffer from postpartum hemorrhage. Furthermore, the findings indicated that FGM leads to an extra one to two infant deaths per 100 births, likely due to the increased risk of difficulties with delivery.3 In addition to these physical harms, long-term consequences include PTSD in girls old enough to remember being cut, and the shame and depression associated with complications. The United Nations Population Fund (UNFPA) compiles and publishes interviews with victims of FGM, including the heart wrenching story of Zainab, a girl subjected to Type 3 FGM at age 8:

“Another girl was infibulated and she died because of the operation. We were so scared and didn’t want to suffer the same fate. But our parents told us it was an obligation, so we went. We fought back; we really thought we were going to die because of the pain… We were lucky, I suppose. We gradually recovered and didn’t die like the other girl. But the memory and the pain never really go away.”2

Despite the medical ramifications, which were likely far more severe and common before the advent of modern medicine, FGM is deeply embedded in various cultures, dating back more than 2000 years. The exact origins of FGM are unknown, though examples of practices akin to FGM have been traced to ancient Egypt, Ethiopia and Greece. The first literary mention of FGM can be found in the writings of Greek geographer Strabo documenting his visits to Egypt in 25 B.C.E. The procedure was again described in the writings of the celebrated second century C.E. Greek physician, Galen. In ancient times, it is believed that FGM was developed as a method to tame the excessive sexual desires of women.4

After millennia of refining the practice of FGM, the procedure remains perilous to women’s health by medical standards. Cutting is typically performed by midwives in unsterile conditions with non-surgical instruments such as knives and razor blades, using little to no anesthesia. Furthermore, in countries where FGM is not condoned by medical authorities, doctors are trained to inform patients of the health risks associated with FGM but are not trained to and are banned from performing the procedure. As a result, women living in industrialized countries whose cultures promote FGM in spite of national regulations often undergo the procedure in secret, putting themselves at further risk.5

The preservation of this practice stems from both religious and sociocultural factors. Dr. Loretta Kopelman, former chair of the Department of Medical Humanities at the East Carolina University School of Medicine, postulated four primary reasons: preservation of group identity; maintenance of cleanliness and health; preservation of virginity and family honor and the prevention of immorality; and the furthering of marriage goals and enhancement of sexual pleasure for men.6 In many societies that practice FGM, marriage is essential for the establishment of social and economic stability, and as such it is difficult to oppose the institution of FGM due to its close ties to a woman’s marriageability.7 In many parents’ minds, FGM is not harming their daughter but rather ensuring her future.4

Regardless of opinion on the matter, FGM and its history run deep within the feminine culture in the 30 nations where it is practiced. For example, in Sierra Leone, the practice of FGM occurs within the Bondo society, also known as the Sande, an all-women society to which nearly 90% of Sierra Leonean women belong. It serves as a community for women to escape their household responsibilities and seek out the comfort and guidance of other women, and as such, FGM in Sierra Leone has proven particularly challenging to oppose. One girl recounted her story after being cut in a Bondo ritual at age 12:

“My mum… said they have bundu [Bondo] societies throughout Sierra Leone and the societies are not entirely bad – they do have a good meaning behind them… I always wondered about what happened to the girls I spent those two weeks with, so I asked my mum. She told me that we missed the fun part of the bundu forest. After the wounds heal, the girls are taught how to do domestic skills like cooking, washing clothes, ironing and everything that has to do with being a good wife and mother.”8

The prevalence of the four types of FGM varies across 30 countries in Africa, the Middle East and Asia. The countries with the highest prevalence include Guinea, at 99%, Egypt, at 97%, Mali, at 92%, and Sudan, at 90%.9 More than 200 million women and girls worldwide have been subjected to FGM in the countries where it is still practiced, with nearly 3 million girls at risk of FGM each year.1

Due to the efforts of grassroots, national and international organizations over the past 40 years or so, FGM has been outlawed in many countries and is considered socially unacceptable in most. Underlying this opposition is the claim that FGM is a fundamental violation of human rights. Furthermore, the practice of FGM has been viewed as a violation of UN conventions on women’s and children’s rights. The practice was first officially conceptualized as a human rights violation at the 1993 World Conference on Human Rights in Vienna. At this conference, FGM became classified as a form of violence against women (VAW), and VAW was acknowledged as falling within the domain of international human rights law.10 Then, in 1997, the WHO, UNICEF and UNFPA issued a joint statement:

“Even though cultural practices may appear senseless or destructive from the standpoint of others, they have meaning and fulfil a function for those who practise them. However, culture is not static; it is in constant flux, adapting and reforming. People will change their behaviour when they understand the hazards and indignity of harmful practices and when they realize that it is possible to give up harmful practices without giving up meaningful aspects of their culture.”11

Despite this statement nearly two decades ago, FGM persists in certain countries and occurs throughout the world due to immigration. For example, in the United States in 2013, more than 500,000 women and girls were considered at risk for FGM because of what is referred to as “vacation cutting:” American-born children of immigrants from countries where FGM is highly prevalent are brought to their parents’ countries of origin to be cut.12

The efforts to end FGM worldwide have further intensified over the past decade, attempting to extend beyond the legal sphere and into the social sphere. According to UNICEF, “Unless legislation is accompanied by measures to influence cultural traditions and expectations, it tends to be ineffective, since it fails to address the practice within its broader social context.”10 In 2008, ten United Nations agencies signed an interagency statement committing to efforts to eliminate FGM. Then, in December of 2012, the United Nations General Assembly adopted the resolution, Intensifying global efforts for the elimination of female genital mutilations. The resolution calls on individual nations to put into action punitive measures and social movements such as education campaigns to protect the rights of women and girls as well as on the international community to provide financial support to put an end to FGM.13

An adolescent girl pictured during a momentous “dropping of the knife” ceremony in Wassu, Upper River Division, Gambia in April 2013. Organized by the NGO, GAMCOTRAP, this marked the end of FGM for hundreds of girls in the area. Source: Arts at LSE.

Along with the opposition to FGM on the legal front, the movement to end FGM has also grown in prevalence among grassroots organizations. One such organization, Equality Now, was founded in 1992 with the goal of protecting the rights of women and girls. For more than two decades, their efforts to end FGM have included advertisement campaigns and videos shared through major international media sources such as BBC and the New York Times, letter-writing campaigns to promote the passage of anti-FGM legislation, blog posts and, starting in late 2016, a compilation of stories from FGM survivors14. Equality Now’s partnership with the Home Office of the UK government led to the creation in 2012 of the “Health Passport,” an information sheet available in 11 languages designed to be carried in a girl’s passport that details the criminal status of FGM in the UK and the support available so as to provide protection against FGM pressures in foreign countries.15 Equality Now also partners with a number of other influential anti-FGM organizations such as Safe Hands for Girls and The Girl Generation. Safe Hands for Girls was founded in 2013 by Jaha Dukureh, a Gambian FGM survivor who was named to Time magazine’s Top 100 Influential People in 2016 for her work.16 The Girl Generation is a social change communications platform that connects and supports local grassroots organizations opposing FGM around the world.17 These organizations are only three of the many organizations working tirelessly to oppose the existence of FGM as a social norm in the hopes that someday it may be eliminated entirely.

Conclusion

Female genital mutilation is a violation of human rights, particularly those of women and children. It is an operation performed for non-medical reasons but carries with it devastating medical complications and is as such an important global health issue. Efforts to oppose FGM date back to the 1920s and have intensified in recent decades. The anti-FGM movement has advanced as far as seemingly possible on the international legal level but still has far to go on the sociocultural one. It is so deeply entrenched within certain cultures that prohibition and punishment have little effect. Although generational analyses have shown that the practice of FGM has been steadily decreasing since the 1970s with the advent of international legislative initiatives, this progress has been slow. According to UNICEF, “Findings suggest that efforts to end the practice need to go beyond a shift in individual attitudes and address entire communities in ways that can decrease social expectations to perform FGM.”10 In other words, to make measurable progress toward the elimination of FGM in the remaining 30 countries where it is heavily practiced will require the mobilization of the international community as a whole to affect the beliefs of individual communities. FGM will not be eliminated by teaching individuals to not cut their daughters but rather by encouraging them to not want to do so.

Jessica Schmerler is a senior in Jonathan Edwards College majoring in Molecular, Cellular & Developmental Biology. She can be contacted at jessica.schmerler@yale.edu.

WHO study group on female genital mutilation and obstetric outcome. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. The Lancet 2006;367:1835–1841.